Frequently Asked Questions

What benefits and services are included in, and excluded from my coverage?

To view a list of your covered benefits and services, please log in to Plan Central. You may also request materials online or call SummaCare Customer Service at the number listed on the back of your member ID card to request a copy of your Schedule of Benefits, Evidence of Coverage, Certificate of Insurance, Provider Policy or Pharmacy Rider.

Are there procedures related to my prescription drug benefits that I should be aware of?

Yes. SummaCare Drug Formularies indicate if a drug has limitations such as Prior Authorization, Step therapy or Quantity Limits. Below is what is required should your medication have one of these limitations:

Prior authorization: If prior authorization is required for a medication, your prescribing physician will need to call the number on your SummaCare ID card and supply clinical information regarding the medical necessity for the requested drug.

Step therapy: Step therapy is the practice of beginning drug therapy for a medical condition with the most cost-effective and safest drug therapy and progressing to other more costly or risky therapy, only if necessary. If a step therapy protocol is in place for a medication, claims for this medication will be covered based on the member's previous medication history. If prior medication history does not meet clinical guidelines, the prescribing physician will need to call the number on your SummaCare ID card and supply clinical information regarding the medical necessity of the requested drug.

Quantity limits: If quantity limits (maximum number of tablets/capsules, etc. per retail prescription) are in place for a medication and your prescribing physician is requesting a quantity in excess of SummaCare’s limit, he/she will need to call the number on your SummaCare ID card to supply clinical information supporting the medical necessity of the increased quantity.

The SummaCare Drug Formulary also indicates Specialty Drugs with an asterisk (*). Specialty drugs are expensive prescription drugs that require special handling and storage and are not always readily available at a retail pharmacy. Specialty Drugs are used to treat chronic or genetic conditions including, but not limited to, Multiple Sclerosis, Psoriasis, Rheumatoid Arthritis, and Viral Hepatitis. All Specialty Drugs require PA. Most SummaCare prescription drug benefits limit Specialty Drugs to a 30 day supply and will only cover them when filled through our contracted specialty pharmacy.

For more information please refer to your Prescription Drug Rider and the SummaCare Drug Formulary.

What are my copayments and other charges I am responsible for?

For copayment and/or coinsurance information specific to your plan, please refer to your Schedule of Benefits. You may view your schedule of benefits by logging in to Plan Central. You may also request materials online or call SummaCare Customer Service at the number listed on the back of your member ID card to request a copy of your Schedule of Benefits.

What benefit restrictions apply to services obtained outside SummaCare’s service area?

To review out-of-network benefit restrictions, please refer to your Evidence of Coverage, Certificate of Insurance or Provider Policy. You may request these materials online or call SummaCare Customer Service at the number listed on the back of your member ID card to request a copy.

How do I submit a claim for covered services?

If you receive care from an In-Network provider, you do not need to submit a claim for the covered services. If you receive care from an Out-of-Network provider, please complete and submit a Medical Claim Form.

How do I obtain information about practitioners who participate in the organization?

You can search for practitioners who participate in the SummaCare network by using the online provider search. Go to www.summacare.com and click on "Find a Doctor or Hospital."

How do I obtain primary care services, including points of access?

To find a primary care physician, go to www.summacare.com and click on "Find a Doctor or Hospital." You can search for a primary care physician by selecting "Family Medicine (PCP)," "General Practice (PCP)," "Internal Medicine (PCP)," or "Pediatrics (PCP)" from the Specialty listing.

How do I obtain specialty care and behavioral health services and hospital services?

To find a hospital, specialist or behavioral healthcare provider, go to www.summacare.com and click on "Find a Doctor or Hospital." To search for a hospital, select "I would like to search for hospitals." To search for a specialist or behavioral healthcare provider, select the appropriate specialty from the Specialty listing.

How do I obtain care after normal office hours?

If you need medical advice after normal office hours, call SummaCare's 24-Hour Nurseline at 1-800-379-5001. If you need emergency care, call 911 or go to the nearest hospital.

How do I obtain emergency care and what is SummaCare’s policy on when to directly access emergency care or use 911 services?

An emergency is defined as a medical condition that manifests itself by acute symptoms of sufficient severity, including severe pain, that a prudent layperson with an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in any of the following: placing the health of the individual or the health of a pregnant woman or her baby in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any body organ or part. If you experience symptoms that meet the definition of an emergency, call 911 for emergency assistance or go to the nearest emergency room.  If your condition does not warrant emergency care consider alternatives. How do I obtain care and coverage when I’m out of SummaCare’s service area?

If you are traveling outside the SummaCare service area, please refer to your member ID card to find your applicable wrap network(s). You may search applicable networks by using SummaCare's online provider search.

How do I voice a complaint?

A complaint may be voiced by calling SummaCare Customer Service at the number listed on the back of your member ID card. You may also submit a complaint in writing. A complaint may be submitted in writing by mailing a letter, fax or email to SummaCare describing the complaint.

How do I appeal a decision that adversely affects coverage, benefits or my relationship with SummaCare?

To appeal a decision, members have 180 calendar days from the date notification of an initial/prospective determination was issued. Appeals should be submitted in writing and mailed, faxed or emailed (appeals@summacare.com) to the attention of SummaCare Appeals.

How does SummaCare evaluate new technology for inclusion as a covered benefit?

SummaCare is committed to providing members with access to the most up-to-date treatment and state-of-the-art care that is both safe and effective. This commitment requires thoughtful evaluation of emerging new technologies on an ongoing basis for inclusion in the SummaCare benefit package. SummaCare's Health Services Management staff queries the following sites on a monthly basis to assess for new medical technologies: Medscape, Hayes Directory, Agency for Health Care Policy and Research, Center for Medicare and Medicaid Services and American Medical Association.